Anthony Chisada, Paul Matsvimbo, Munekayi Padingani, Tsitsi Siwela of Jhpiego,the USAID ZAPIM Project, Harare, Zimbabwe, and the Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe presented their experiences using death audits at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings follow.

Nearly 50% of the Zimbabwean population is at risk for malaria. Total numbers of malaria related deaths have remained almost constant over the past 5 years. The National Malaria Control Program’s National Malaria Strategic Plan aims to reduce malaria-related deaths by 90% from 2015 levels (462 deaths) by 2020.

To improve severe malaria care and reduce mortality, NMCP documents and investigates all malaria deaths to ascertain the cause of the death and understand if and how it was avoidable. Malaria death audit meetings are held quarterly with health facility staff using a standard death investigation form and case management notes and form a learning platform to look at qualitative and quantitative data related to the deaths.

The audits also examine the quality of care offered as per treatment guidelines and seek to identify ways to prevent future malaria deaths based on omissions and errors in presented cases.

This review examines the findings from death audit meetings facilitated by the PMI-funded Zimbabwe Assistance Program in Malaria project in the Zimbabwean provinces of Mashonaland Central, Mashonaland East and Matabeleland North. Six death audit meetings were conducted over an 18-month period, resulting in a total of 80 deaths audited. The audited deaths were purposely sampled for the potential learning value they offered and to diversify lessons learned.

According to audit reports, the main contributing factors to malaria deaths included: delayed presentation by patients, lack of comprehensive assessment and documentation of cases, inadequate care for patients with reduced level of consciousness and shock, inadequate follow-up of patient progress, lack of supportive investigations, and lack of access to renal replacement therapy/dialysis and blood transfusion.

Most deaths in age groups: under 5s(30%) and over 15(44%). Children are at risk of dying from malaria because of underdeveloped immunity, women taking children to gardens at night, delayed presentation since mothers are busy. Problem most pronounced in UMP. People over 15 years also at risk of dying: Suggestive of exposure as they indulge in outdoor activities without any protection from mosquito bites.

Death audits reapportion delays (3rd delay increased from 8% to 28%). First delay remains the major contributory factor- need for strengthening SBCC efforts. Malaria death audit meetings enhances the usefulness of the malaria death surveillance system and provides an opportunity for identification and discussion of health system challenges. Some challenges identified are rectifiable thus mitigating deaths. These enable holistic patient care: Identification and management of co-morbidities is critical. Findings contributed to justification of introduction malaria clinical mentorship for improving QoC.

The introduction of malaria death audit meetings has added an active, learning platform to complement the use of the malaria death investigation form and also served as a useful learning tool within Zimbabwe’s clinical mentorship program. Regular malaria death audit meetings are potentially useful in improving malaria care and reducing malaria related deaths.

IMC together with the National Malaria Control Program has been strengthening Health Care Provider Capacity. 54 health districts have been covered by IMC direct support where 1819 providers were trained. Training reached 185 trainers/supervisors on revised training Modules who then trained 1,819 health care providers from 1,349 health facilities in 54 districts on new guidelines

IMC Strengthened National Malaria HMIS. This included training 1,300 (72%) health workers to enter data into monthly reporting forms. Also trained were 326 data managers on HMIS and data use for decisionmakers. The malaria data collection system was integrated into national HMIS using DHIS2. To facilitate this the national HMIS manual was revised and distributed. Data Quality was improved through malaria data review and validation at district levelUltimately these interventions resulted in Improved Malaria Services. More confirmed simple malaria cases received artemisinin-based combination therapy (65% in 2013 to 90% in 2017). More women received three doses of IPTp3 (14% in 2014 to 51% in June 2018). More suspected cases tested for malaria (65% in 2013 to 96% 2017). More women received insecticide-treated nets at antenatal care. There was Better accuracy in reporting of malaria key indicators.

Improved services led to decreased national malaria fatality rate. In the General population there was a decrease in malaria deaths of 34% and a decrease in overall fatality rate by 47%. Among pregnant women there was a decrease in malaria deaths by 91% and a decrease in malaria fatality rate by 93%. For Children under 5 years of age, there was a decrease in malaria deaths by 34% and a decrease in fatality rate 48%

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

The 30thAfrican Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

The time is ripe for a revitalization of the primary health care (PHC) movement. “Health for All through Primary Health Care” (HFA) was first envisioned at the 1978 International Conference on Primary Health Care (World Health Organization and UNICEF), and was enshrined in the Declaration of Alma-Ata. The HFA goal of bringing essential, affordable, scientifically sound, socially acceptable health care provided by health workers who are trained to work as a health team and who are responsive to the health needs of the community, guided by strong community engagement by the year 2000 but has not been fully met. Fortunately the vision of Alma-Ata has taken root, sprouted and flourished in a number of locations.

Thanks to the vision and intellectual and political leadership of Dr. Tedros Adhanom Ghebreyesus, the then Minister of Health of Ethiopia and recently elected Director General of the World Health Organization, Ethiopia is an outstanding example of the Alma-Ata legacy. Access to PHC services was greatly expanded through the training of 40,000 Health Extension Workers (women from the local area with one year of training, each of whom serve 2,500 people and receive a government salary), recruitment of 3 million community female health volunteers (called the Health Development Army), and engagement with communities to enable them to take responsibility for improving their health.

Representatives from more than half of sub-Saharan Africa countries have come to Ethiopia to see its PHC system in action. Because of this interest, in 2016 the Federal Ministry of Health of Ethiopia established the International Institute for Primary Health Care – Ethiopia, with seed funding from the Bill & Melinda Gates Foundation and technical support from the Johns Hopkins Bloomberg School of Public Health. Our goal is for the Institute to become a global center of excellence for training, knowledge dissemination and research in primary health care, supported by multiple donors.

The Institute has begun to provide formalized short-term training to high-level policy makers and officials, program planners and managers, as well as to those engaged in service delivery, to see first-hand how an effective national PHC system functions. Trainees come from within Ethiopia and around the world. Trainees also visit communities, meet their leaders, and observe primary health care providers at work. Trainees will return to their home country with renewed energy and new vision and skills to revitalize their own primary health care system.

The Institute will also conduct and support research that yields evidence to guide ongoing strengthening of the Health Extension Program, and will rapidly disseminate open access information about recent advances in PHC. The Institute marks a significant step forward on the road to achieving the Alma-Ata vision of Health for All.

A website for IIfPHC-E is being built to provide further information about these programs and will be available at: www.iifphc.org.

8Coordinator for Johns Hopkins University Support of the International Institute for Primary Health Care – Ethiopia, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

In wars in malaria endemic areas, malaria can cause more damage than what occurs on the battlefield. The United States just observed its annual Memorial Day where those who died serving the country are remembered. Wing Beats, the journal of the Florida Mosquito Associations reported on the status of malaria vectors in the state of Georgia and stressed the damage malaria did during the US Civil War:

“From 1861 to1866 malaria was the second most commonly diagnosed ailment – diarrhea/dysentery was first – among Union troops, with over 1.3 million cases. Although sold iers native to the South were much more likely to have experienced malaria growing up, they also suffered deaths and incapacitation that affected the timing and outcome of battles.”

During the Korean conflict, “paragonimiasis, malaria, and amoebiasis were the most fatal parasitic diseases during the early 1950s in the Korean Peninsula,” and consequently were responsible for deaths of prisoners of war. The U.S. military received a severe damage during World War II in the Pacific where it was said that “more soldiers were lost by malaria than by battle itself.” The experience led to hundreds of units specialized in controlling malaria in Korea.

Today malaria continues to produce death in conflict zones. “The area of Walikale in North Kivu, Democratic Republic of Congo, is intensely affected by conflict and population displacement.” The most frequently reported cause of death among the local population was fever/malaria at 34.1% .

During the civil war in Côte d’Ivoire “the availability and use of protective measures against mosquito bites and accessibility to health care infrastructure deteriorated.” A study of resettlement camps of displaced families after the Angolan civil war “Malnutrition was the leading cause of death (34%), followed by fever or malaria (24%) and war or violence (18%).”

Some of the most highly malaria endemic countries in the world still experience conflicts. Malaria kills directly, it can be used as a weapon, and war disrupts efforts to control it. If we are to “end malaria for good,” we might also think about trying to end war and conflict, too.

What it is that makes a disease “eradicable,” or more correctly what makes it possible to eliminate malaria in each country leading to the total eradication world-wide. Bruce Aylward and colleagues identified three main sets of factors by drawing on lessons of four previous attempts to eradicate diseases (including the first effort at malaria eradication in the 1950s and ‘60s).[1]

biological and technical feasibility

costs and benefits, and

societal and political considerations

So far smallpox is the only success because as Aylward et al. pointed out biologically, humans were the only reservoir and on the technical side a very effective vaccine was developed. The eradication campaign was promoted in clear terms of economic and related benefits. While the early malaria eradication efforts started with political will and recognition of the potential economic benefits of malaria eradication, the will was not sustained over two decades. On the technical side at that time there was only one main tool again malaria, indoor residual insecticide spraying, and mosquitoes quickly developed resistance to the chemicals. Are we better able to meet the three eradication criteria today?

Today’s technical challenges are embodied in intervention coverage problems. The World Malaria Report of 2015[2] (WMR2015) explains that the problem is most pronounced in the 15 highest burden countries, and consequently these showed the slowest declines in morbidity and mortality over the past 15 years. Use of insecticide treated nets and intermittent preventive treatment for pregnant women hovers around 50%, while appropriate case management of malaria lags well below 20%, a far cry from the goals of universal coverage. A further explanation of the technical challenges as outlined in the WMR2015 lies in “weaknesses in health systems in countries with the greatest malaria burden.”

The economic benefits criteria should be most pronounced in the high burden countries, but these are also generally ones with low personal income. Ironically, the WMR2015 points out that it is the high costs of malaria care and the malaria burden that further weaken health systems. More investment is needed in order to see more economic benefits.

Biological challenges to elimination are also identified in the WMR2015. Examples of existing and arising biological difficulties include –

Plasmodium vivax malaria which requires a more complicated regimen to affect a cure.

“P. falciparum resistance to artemisinins has now been detected in five countries in the Greater Mekong subregion.” Historically chloroquine and sulfadoxine-pyrimethamine resistance spread from this area and now artemisinin resistance marks a ‘Third Wave” of resistance emanating from the region.[3]

“Human cases of malaria due to P. knowlesi have been recorded – this species causes malaria among monkeys in certain forested areas of South-East Asia,” and so far human-to- human transmission has not been documented.

On the positive side greater political support to elimination efforts has been expressed by the African Leaders Malaria Alliance (ALMA) who met at the African Union Leaders Summit in Addis Abba early in 2015 and resolved to eliminate malaria by 2030.[4] This call to action was backed up with an expansion of ALMA’s quarterly scorecard rating system of African countries’ performance to include elimination indicators.[5]

In conclusion, political will exists, but needs to be backed with greater financial investment in order to produce economic benefits. Time is of the essence in taking action because biological and technical forces are pressing against elimination. 2030 seems far, but we cannot wait another 15 years to take action against these challenges to malaria elimination.

[3] IRIN (news service of the UN Office for the Coordination of Humanitarian Affairs). “Third wave” of malaria resistance lurks on Thai-Cambodia border. August 29, 2014. http://www.irinnews.org/report/100549/third-wave-of-malaria-resistance-lurks-on-thai-cambodia-border

Chulwoo (Charles) Park who has been undertaking the Masters of Science in Public Health at the Johns Hopkins Bloomberg School of Public Health is sharing herein his experiences with the LiST tool in African countries.

The Lives Saved Tool (LiST) is a computer-based tool that estimates the impact of scaled up health intervention packages in a quantitative manner. By modeling complex mathematical relationship of coverage difference among interventions for maternal, neonatal and child health (MNCH), LiST shows us quantitative results, such as mortality rates, incidence rates, number of cases averted, percentage of stunting and wasting, number of cause-specific death and lives saved.

Especially, LiST can project and run multiple scenarios for subnational target population in the country not only to evaluate existing MNCH project but also prioritize investments for the future based on the quantitative results. World Vision International (WVI) has implemented LiST analysis to strengthen its evaluation and strategic planning methods for MNCH projects since 2013.

Recently, the mid-term evaluations for Access to Infant and Maternal (AIM)-Health project in Kenya, Mauritania, Sierra Leone, Tanzania, and Uganda were conducted through mixed methods analysis, both qualitative research (in-depth interview and focused group discussion) and quantitative research (LiST) from June to September of 2014.

Subsequently, LiST was solely utilized to quantify the retrospective impact of Water, Sanitation, and Hygiene (WASH) project in Southern Africa Region (SAR), Malawi, Mozambique and Zambia between 2010 and 2014. The significant impact indicates that the combined effect of all five WVI WASH interventions (improved water source, home water connection, improved sanitation, hand washing with soap, and hygienic disposal of children’s stools) have prevented 989,745 diarrhoeal cases among the under-five target population of 506,019 children.

In other words, every single young child prevented 1.96 cases of diarrhea, and prevention rate for diarrhoea was 13% throughout the implementation period. Another results indicate that WVI’s WASH project contributed a 209% mean increase in percentage of under-five lives saved and 15.5% mean decrease in under-five mortality rates across SAR.

Chulwoo (Charles) Park, MSPH ’15

Johns Hopkins Bloomberg School of Public Health, Department of International Health, Division of Global Disease Epidemiology and Control

The largest portion of infant deaths occurs in the neonatal period. During those first 28 days, the child is at risk from a variety of problems arising from delivery complications, infections and simply not being kept warm.

In malaria endemic areas there is the small but important problem of malaria transferred from mother to child, or congenital malaria. The problem occurs with both Plasmodium vivax and falciparum.

One would hope this problem could be avoided if prevention of malaria in pregnancy was practiced using insecticide treated nets, intermittent preventive treatment (IPTp) and prompt and appropriate case management, but studies still find placental and cord parasiteamia in countries where such interventions are supposed to be integrated into antenatal/prenatal care. In Colombia, “An association was found between congenital malaria and the diagnosis of malaria in the mother during the last trimester of pregnancy or during delivery, and the presence of placental infection.”

Countries are in the process of shifting to the relatively new WHO guidance on IPTp that encourages monthly doses of sulfadoxine-pyrimethamine from the beginning of the second trimester up until delivery. Countries are also trying to ensure universal coverage of ITNs so that women will be using nets prior to even becoming pregnant.

We still have trouble administering to take just two doses of IPTp, but if we want to prevent congenital malaria, we need to ensure that women are protected from malaria in their placentas and are free from parasites right up until they give birth and thereby prevent another cause of neonatal mortality.

Much of the discussion around global health and post-Millennium Development Goals focuses on non-communicable diseases (NCDs) including cardiovascular problems, diabetes, cancers and the the like.Â While it is important to recognize that low income nations are not plagued with both communicable and non-communicable diseases, we do not want the greater focus on NCDs in richer countries to overshadow the problems of malaria, pneumonia, TB, diarrhea and other child killers in poorer countries.

A major reason for us not to lose focus on communicable diseases was recently reported from the Wellcome Trust on research they have supported in Malawi. The researchers found that the malaria parasite, Plasmodium falciparum, is able to “cause inflammation in blood vessel walls, making them more sticky so that the infected red blood cells can cling to the sides. Being able to stick to the blood vessels in vital organs allows the parasite to hide away from the immune system, a process called sequestration. When it occurs in the brain it causes a more severe form of the disease called cerebral malaria, associated with seizures, coma and sometimes death.”

The researchers also surmised that if this complication does not kill people in childhood, the damage to blood vessel walls can have more long lasting effects. In particular they noted that, “Chronic changes to the blood vessels like these could an important contributing factor to cardiovascular disease later in life.”

The link between malaria and Endemic Burkitt lymphoma (eBL) continues to be explored. Recently adding to this long history of eBL research, Peter Aka and colleagues reported that. “Antiâ€“HRP-II (Plasmodium falciparum histidine-rich protein-II) antibodies suggest that recent malaria infection triggers the onset of eBL.”

In a review of intrauterine growth retardation (IUGR) Demicheva and Crispi observed that, “Several clinical and experimental studies showed that IUGR fetuses present signs of cardiac dysfunction in utero that persist postnatally and may condition higher cardiovascular risk later in life.” In endemic regions, malaria in pregnancy is a major cause of IUGR and thus low birth weight.

Preventing malaria therefore saves lives now and in the future. Ignoring malaria now adds greater burdens to the health system and national productivity tomorrow. We need to maintain our investments in malaria both globally and in and by endemic countries themselves.

“The estimated incidence of malaria has decreased globally, by 17 per cent since 2000. Over the same period, malaria-specific mortality rates have decreased by 25 per cent. Reported malaria cases fell by more than 50 per cent between 2000 and 2010 in 43 of the 99 countries with ongoing malaria transmission.”

While the overall tenor of the report veers toward the positive, the authors had to explain that, “Although these rates of decline were not sufficient to meet the internationally agreed targets for 2010 of a 50 per cent reduction, they nonetheless represent a major achievement.”Â Ironically, the map at the right, taken from the report does not even include a shading for 80% and higher – the Roll Back Malaria target for 2012. Inadequate intervention coverage and the financial and health systems weaknesses contributed to the coverage gap, in spite of calls for universal coverage in 2009.

The big push toward universal coverage did result in more nets, but some countries are still in the process of trying to get the first round of mass distribution finished.Â In light of Global Fund Round 11 cancellation and the world economic crisis, fears exist that replacement nets, likely needed by 2013, can be bought. The MDG report echos this concern: “There are worrisome signs, however, that momentum, impressive as it has been, is slowing, largely due to inadequate resources.”

Over six million treated mosquito nets will be distributed to households in 2012 and 2013 and around 500,000 Long Lasting Insecticidal Nets (LLINs) will be given to pregnant women and children under five years in 2012, the National Malaria Control Program Director, Dr. Corine Karema, has said. “Currently we are in the phase of replacing the Long Lasting Insecticidal Nets (LLINs) distributed in 2010,” Dr Karema said, adding that families which didn’t receive them in 2010 will be assessed so that they can also get nets.

Not only does Rwanda’s effort represent replacement of the old nets, but also recognizes the need to provide nets in an ongoing manner during routine health services like antenatal care. Let’s hope that this sets a good example for other countries to make a commitment to find the funds – locally and/or internationally to ensure that the MDG for malaria morbidity and mortality reduction will not be sidetracked.

https://t.co/yKKsmAEpSv @MinSanteRDC #Ebola 23 May 2019: Since beginning of epidemic, cumulative number of cases is 1,888, of which 1,800 confirmed 88 are probable. In total, there were 1,254 deaths (1,166 confirmed and 88 probable) and 492 people cured. 11 new confirmed cases